levels of military medicine Flashcards
1
Q
self/buddy aid to battalion aid station
A
role 1
2
Q
brigade or division, brigade support batallion; area medical support companies, forward surgical teams; 1st level w/ blood, limited x-ray and lab, patient hold capability
A
role 2
3
Q
corps level- combat support hospital; in theater military treatment facilities; full surgical care, hold, lab, radiology to include CT; stabilizing care for evac
A
role 3
4
Q
definitive care; out of theater; full rehab care; teriary care
A
role 4
5
Q
hospitals in the us
A
role V
6
Q
MC causes of spinal cord injury?
A
- vehicl
- falls
- violence
7
Q
what is the MC injured part of the spine?
A
c-spine specifically c2 and c5-c7
8
Q
what is the second MC site of injury to the spine?
A
thoracolumbar
9
Q
how many pairs of spinal nerves and where? also where does the spinal cord terminate?
A
L1, L2
31 pairs
c=8 t=12 l=5 s=5 c=1
10
Q
is injury to the thoracic spine common?
A
no, severe traumatic forces. also the canal is skinnier so injury to the cord increases
11
Q
sacral fractures that involve the central sacral canal can produce?
A
bowel and bladder dysfunction
12
Q
when is the spine considered unstable?
A
if two of the columns are involved (DENIS: anterior, middle, posterior
13
Q
what should you assume about every spine fracture in the ED?
A
that they are unstable until expert consultation w/ spine surgeon
14
Q
how will a complete neurologic spinal lesion present?
A
absence of sensory and motor function below the injury
15
Q
what is spinal shock?
A
loss of all reflex activities below the area of the injury, so lesions can’t be determined as complete or incomplete until after
16
Q
descending motor pathway that originates from the cerebral cortex and cross in lower medulla?
A
lateral corticospinal tract
17
Q
injury to corticospinal tract results in?
A
ipsilateral muscle weakness, spasticity, INCREASED DTR and babinski sign
18
Q
tract that enters dorsal grey horn where they immediately cross and ascend?
A
spinothalamic tract
19
Q
spinothalmic tract injury will result in?
A
contralateral loss of pain and temperature sensation below the level of injury
20
Q
tract that enter’s the spinal cord, but does not immediately decussate?
A
dorsal (posterior) column
21
Q
dorsal column injury results in what?
A
ipsilateral loss of vibration and position sense
22
Q
what injuries must be present for complete loss of light touch?
A
spinothalmic and dorsal columns
23
Q
when is spinal immobilization no longer recommended?
A
fully conscious, neurologically intact patients w/ isolated penetrating neck injury
24
Q
what symptoms can indicate present or impending respiratory compromise
A
dyspnea, palpitations, abdominal breathing, anxiety, high cervical spine injury
25
evaluation of cauda equina?
MRI
26
what happens if t1-t4 are compromised?
loss of sympathetic innervation of the hear bradycardia
27
what must you do w/ neurogenic shock?
rule out other causes of hypotension first
28
what can cause an imcomplete to mimic a complete?
spinal shock
29
what is nexus?
```
Neurological focal deficit
ETOH
X distracting injuries
Unconsious/ AMS
Sore midline cervical tenderness
```
30
consious
GCS <15, not oriented oriented ppte, 3 things in 5 in, inability or delayed response to external stimuli
31
canadian cervical
no high risk factors
low risk factors that allow rom
patient able to rotate 45 degrees
32
thoracolumbar frx is at high risk for what?
aortic, intrathoracic or intra-abdominal
33
sacral fractures are associated w/ what?
frxs of the pelvis
34
what is mild/moderate/ and severe GCS?
14-15, 9-13, 3-8
35
what is the low limit for cerebral perfusion pressure?
<60 mmHg
36
what must your mean arterial pressure be above when you don't have an ICP monitor?
80
37
what causes secondary brain injury?
massive release of release of neurotransmitters w/ activation of n-methyl-d-aspartate causes water to go into spaces and ends in cell death
38
two casues of brain edema?
cellular swelling (from ionic shifts)
extracellular edema (results from direct damage to or break down of the blood brain barrier)
39
what is the most common brain herniation?
uncal
40
patient presents w/ ipsilateral fixed and dilated pupil, this progresses to contralateral motor paralysis, what has occured?
uncal herniation, then pyramidal tract compression
41
patient presents w/ bilateral pinpoint pupils, bilateral babinski sign and increased muscle tone. This is followed by fixed midpoint pupils, prolonged hyperventilation, and decorticate posturing, dx?
central transtentorial herniation
42
patient presents w/ pinpoint pupils, flaccid paralysis, followed by sudden death?
cerebellotonsillar herniation
43
patient presents w/ conjugate downward gaze, abscence of vertical eye mvments and pinpoint pupils.
upward transtentorial herniation
44
motor score of gcs correlates w/ what?
outcome
45
epidural lesion looks like what?
football
46
what do you need to do before intubating?
preintubation GCS
47
where is a decorticate injury?
higher level of midbrain
48
what to do for uncooperative combative patient?
intubate and sedate
49
what does hyperventilation do?
cerebral vasoconstriction keep PCO2 35-45
50
what suggests increased ICP?
bilateral fixed and dilated pupils, CT pathology, decerebate and decorticate posturing, change in mental status
51
treatment for traumatic brain injury?
hypotension, hypoxemia, hypercarbia, hyperglycemia
52
what are the induction and paralytic agents
etomidate + rocuronium
propofol + succinylcholine
53
what do you need to have MAP and systolic BP above to prevent hypotension and secondary brain injury?
>90 and >80
54
what are signs of impending trantentorial herniation?
unilateral or bilateral pupillary dilation/ hemiparesis, motor posturing, neurologic deterioration, monitor w/ GCS and repeat CT
55
what CPP must you maintain to adequately profuse the brain?
55-60
56
what patient should you consider ICP monitoring in even if there brain CT is normal?
over 40, unilateral/bilateral motor posturing, systolic BP <90
57
what is a bad ICP
>20mm hg
58
treatment for scalp laceration?
direct pressure, licaine w/ epi, clamp or ligate bleeding vessels
59
what to do if skull fracture?
ct scan, explore them gently
60
fractures that are open, depressed, involve a sinus or a re associated w/ pneumocephalus recieve waht?
vanc 1, ceftriaxone 2
61
what is the MC basilar skull fracture?
petrous protion of the temp bone, external auditory canal, and the tympanic membrane
62
patient presents w/ otorrhea or rhinorrhea secondary to?
dural tearing w/ basilar skull fracture
63
what is CI in cribiform fracture?
NG tube
64
patient spresents w/ CSF leak, mastoid ecchymosis (battle), periorbital eccymosies (racoon) hemotympanum, vertigo, decreased hearing or deafness/ seventh nerve palsy, + beta transferrin? dx. trx
basilar skull fracture
neurosurgeon, as about abx ceft 2, vanc 1
elevate head of bed
lumbar drain
65
contusions are associated w/ what?
subarachnoid hemorrhage
66
2 way contusions occur?
at site or contrecoup on the opposite side
67
treatment for contusion?
serial CTs because they can take a while to show up especially if coaulopathy
68
patient presents w/ HA, photophobia, meningeal signs, blood in CSF? dg. treatment
subarachnoid hemorrhage, performed 6-8 hrs post injury
69
patient presents w/ hx of loss of consciousness, AMS followed by lucid period and subsequent rapid neurologic demise? dx
epidural if recognized early expect a full recovery, from high pressure arterial bleed
70
subdural hematoma is from what?
sudden acceleration/decerlatoin that tears bridging dural veins
71
who is more likely to get a subdural hematoma?
elderly, alcoholics and kids <2 y/o
72
when does a subdural hematoma become chronic>
2 weeks
73
what does a subdural hematoma look like on ct?
moon, might be easier to see on MRI or CT w/ contrast
74
treatment for subdral hematoma?
surgery for acute and subacute, chronic may not need surgery
75
treatment for gun shot wound to head?
intubation
abx: vancomycin + cefriaxone
76
treatment for head stab wounds?
admit, abx, surgery to remove
77
most frequently injured organ and most frequently injured in sports accident?
liver then spleen
78
assume and penetrating injury to lower chest, pelvis, flank or back has what?
penetrated the abdominal cavity until proven otherwise
79
young and healthy patients can do what w/ intra-abdominal injuries?
compensate for a long time
80
pt presents w/ hx of direct blow to abdomen/sudden muscle contraction now has pain w/ flexion and roation and ttp. also has palpable mass inferior to the umbilicus. dx
abdominal wall injury, rectus abdominis hematoma
81
what might be the only clue indicating blood loss from a solid organ injury?
increased pulse pressure
82
what injuries refer to the shoulders?
liver and spleen
83
what predisposes you to splenic injury?
pregnancy and mononucleosis
84
hollow viscious injuries produce what kind of symptoms?
blood loss and periotoneal complaints from contamination by GI contents
85
patient presents w/ hx or rapid deceleration they hit the steering column/ hitting handlebar?
pancreatic injury
86
patient presents w/ ab pain distension and vomiting?
duodenal hematoma
87
what is the primary diagnostic study for abdomen injuries?
FAST focused assessment w/ sonography for trauma
88
what is so great abou the fast?
rapid identification of free intraperitoneal fluid in the hypotensive patient w/ blunt abdominal trauma
89
where is a good place to see a hemoperitoneum?
morrison's pouch
90
what is the noninvasive gold standard for diagnois of an abdominal injury?
abdominopelivic CT w/ IV contrast
91
what is the ideal study for duodenum and pancreas and can differentiate the amount and type of free fluid in the abdomen, and grade of injury?
CT w/ IV
92
what is the gold standard therapy for patients w/ significant intra-abdominal injuries?
laparotomy: allows for complete evaluation of retroperitoneum and abdomen
93
who needs lapartomy?
persistent hypotension, abdominal wall disruption, or peritonitis
94
when should an abdominal patient return to the ER?
fever, vomiting, increased pain, symptoms of blood loss (dizzy, weak, fatigue)
95
#1 cuase of death 1-44 y/o and number 3 overall?
trauma
96
what are the essential characteristics for a level 1 trauma center?
24 hr. availability in all subspecialities
24 hr. availability of neuroradiology and hemodialysis
program that establishes and monitors effect of injury prevention and education efforts
organized trauma research program
97
what does ED care begin w/?
intial assessment for potential life serious injuries
98
patient presents w/ absent breath sounds, initialy chest tube >1000ml/>200 ml indicating vas inj. or massive hemothorax?
thoracotomy/ video assisted thoracic surgery
99
up to 30% of blood can be lost w/ only mild tachycardia and decresed?
pulse pressure
100
if there is no improvement after adminstering 2L of crystalloid what to do?
transfuse type O (negative if woman of childbearing age)
101
what to do w/ open pelvic fracutes?
wrap or sling
102
what to do for patient recieving >10 prbcs?
give 1:1 prbc w/ FFP
103
if GCS <15 assume what?
significant head trauma
104
what can hypothermia cause?
bleeding and coagulopathy
105
what should prompt immmediate transport to or for penetrating abdominal injury?
abdominal tenderness
distension
hypotension
106
gunshot wound trx?
almost all get emergent exploratory larparotomy
107
who should get a thoractomy?
penetrating chest trauma w/ witnessed signs of life during transport, or in the ED
108
what is part of the secondary survey?
cant be started until after basic functions are corrrected
```
scalp lacerations
tympanic membrane
neck and thorax
facial trauma
urinary meatus
rectal
prostate
manual/speculum
```
109
if meatal blood is present and the prostate is displaced what do you have to do?
perform RUG before instering cath
110
what are the most frequently missed conditions?
orthopedic but also esophagus, diaphragm and small bowel
111
when must a tertiary exam be completed
w/in first 24 hours
112
what is required in gunshot wounds to the torso?
chest X-ray
113
what can fast identify
intraperitoneal bleed, pericardial tamponade, pneumothorax, and hemothorax
114
what are routine labs?
blood type and screen, hemoglobin level, urine dipstick testing for blood, ethanol level, hcg
115
ams order what?
glucose
116
>55 consider what?
ecg and troponin
117
what exams should you do before transporting a patients?
primary and secondary
